Clovis Registration – Central Valley Love Notes

We are so glad you've decided to join us for a Love Notes event in Clovis!

Please take a few minutes to complete this registration form. Once we've received your form, we'll be in touch with more details.

Registering for:

Student Name:

First

Last

Age

Gender:

Address:

Address Line 1

City

State

Zip Code

Email:

Phone:

Has your child experienced foster care or adoption?

Please list any food allergies or dietary restrictions.

Does your child have any medical conditions, disabilities, or behavioral issues the staff should be aware of?

Please provide a brief explanation and helpful tips for interacting with your child.

In Case of Emergency, Please Contact:

First

Last

Emergency Contact Phone:

Relationship to Attendee:

Parent/Legal Guardian Name:

Phone:

Parent/Legal Guardian Signature:

Clear Signature

Today's Date

Medical Insurance/Policy Company Name:

Policy/ID Number: